October 4, 2001
Contact: Sylvia Gaudette
202-331-2790 Ext. 309

AHQA Statement on the "Medicare Regulatory, Appeals, Contracting, and Education Reform Act of 2001"

The American Health Quality Association (AHQA) is the national membership organization representing the private state-based Peer Review Organizations (PROs). This national infrastructure develops quality improvement and evaluation programs to improve health care quality in Medicare. The PROs also provide Medicare beneficiaries with the very important right to appeal a notice of discharge from Medicare participating hospitals.

The Benefits Improvement and Protection Act of 2000 (BIPA 2000) created additional rights for Medicare Beneficiaries by allowing them to appeal a notice of discharge or termination of care from a skilled nursing facility, rehabilitation facility or home health setting. The Medicare Regulatory, Appeals, Contracting, and Education Reform Act of 2001 expands the PROs' current appeals responsibilities to include the implementation of these new appeals.

AHQA commends the House Energy and Commerce Committee for recognizing that this important new beneficiary protection must be implemented by highly qualified organizations that patients, doctors and administrators can trust. The PROs are physician-led organizations that operate in every state. They will assure that each appeal is reviewed by a practicing physician with expertise in the specialty or subspecialty appropriate to the patient's condition and needs. They will also assure that reviews are conducted by physicians in the state in which the patient is being treated.

This reform act builds upon the PROs' current hospital discharge appeals process that has been in place since 1987 -- a part of the Medicare appeals system that works. While other parts of the appeals system may require additional review and consideration, and changes to those parts included in BIPA 2000 are delayed by this bill, the expanded right to appeal the continuation of care outside of the hospital system is a proactive measure that Medicare beneficiaries should be able to exercise as soon as possible. This bill recognizes the value of post-acute facilities and the growing emphasis that will be placed on these settings as the Medicare population grows.

We will continue to work with the Committee to further refine this legislation. For example, to fully assure a dependable appeals system for Medicare beneficiaries, the funding for these new appeals must be adequately supported by the Medicare trust fund and the timeframes for implementation must coincide with the PRO contracting process. Additionally, to create a system that offers reliable access and service, AHQA believes the committee should include this new responsibility in the PRO Medicare contracts beyond the transition period set forth in the bill.